The provision of health care services to patients depends on the maintenance of a substantial amount of patient information, including both medical information relating to patient treatment(s) and non-medical information utilized for administrative purposes.
In the past, certain health care providers maintained patient information manually on multitudes of physical paper forms that correspond to segments of medical and non-medical patient information. The total set of collected medical and non-medical information forms for a patient constitutes a patient chart. Health care providers generally create these forms to define and record one or more segments of the patient information for a particular medical need (e.g. an assessment tool, a medical history, a physician order, etc.) or non-medical need (e.g. contact information, insurance information, referral, billing, etc.). The data items on the forms can be referred to as “Charting Items”. Some examples of medical Charting Items for an assessment tools form are heart rate, temperature, blood pressure and weight. Some examples of non-medical Charting Items for contact information form are name, address, phone and insurance number. The maintenance of the patient includes the maintenance of these individual Charting Items.
The maintenance of the patient information in physical charts has several disadvantages. In particular, the physical charts can be lost or damaged. Also, the data integrity can often be compromised on the physical charts due to illegible handwriting, or careless annotation and marks. The forms and Charting Items can also be created ad hoc, and may change without a consensus from other medical practitioners. In addition, the medical terminology and practices constantly change, and/or become obsolete. Furthermore, the duplication of the information can also present a problem because many forms may require basic information, such as vitals, contact or insurance information as part of the treatment or identification, and this information is often duplicated from one form to another.
The conventional electronic patient charting information systems and methods also have certain disadvantages. In particular, prior art patient charting applications are designed similarly to the traditional computer software systems, often ignoring the dynamic nature of the problems associated with the physical patient charts. Also, technologies such as relational databases and procedural (or structured) programming languages are not intended to be used in a dynamic manner, which is the nature of the current patient charts. Indeed, the traditional methods for automating the maintenance of the patient information, which utilize relational databases, do not meet the demands of the ever-changing patient charting environment. The relational databases have shortcomings when the Charting Items are added to the database structure that require a re-generation of the database and re-copying of the data.
The prior art methods and systems for entering and viewing information also do not emulate the physical forms that are used for the patient information. In particular, the graphic screens are traditionally designed for one-time data capture of information, and the entry of the data on a screen-by-screen basis, in a sequence, is often confusing to the user. The navigation through a succession of the screens is a cumbersome and costly operation if only a single change is required. The screens also have a similar drawback as that of the databases, e.g., when adding the Charting Item. For example, when another Charting Item is added, the screen must be regenerated from the development level by the conventional systems and methods. The health care providers often have to adapt new practices in order to utilize the current charting systems. These changes have to be implemented by the software engineers who are not familiar with the medical field. Thus, the necessary changes may not necessarily be implemented in a proper or accurate manner.
The problems inherent in the general-purpose databases and the conventional patient information databases illustrate a need for a system, process and logic element that are flexible for organizing, recording and displaying medical patient care information. Additionally, there exists a need for a system, process and logic element which are easy to use, and can be learned by the medical personnel who have limited experience with computers or software systems.